392701008-3-10-2022-27-AS-MBIR-CCE3PD-20220310172521

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392701008
Report Date: 03/10/2022
Date Signed: 03/10/2022 05:26:30 PM

Document Has Been Signed on 03/10/2022 05:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	PLACE CALLED HOME		FACILITY NUMBER:	392701008
ADMINISTRATOR:	VARGAS, BRANDI		FACILITY TYPE:	740
ADDRESS:	25820 MAGNOLIA AVE		TELEPHONE:	(714) 948-0381
CITY:	ESCALON	STATE: CA	ZIP CODE:	95320
CAPACITY:	11	CENSUS: 0	DATE:	03/10/2022
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Nataley Martinez		TIME COMPLETED:	03:50 PM

NARRATIVE

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On 3-10-22 at 3:00pm, an informal meeting was held with Licensee Nataley Martinez to discuss recent issues arising at facility. Present at the meeting were Regional Manager Krystall Moore, Licensing Program Manager (LPM) Stephanie Doub, Licensing Program Analyst (LPA) Michael Bilger, LPA Sarah Hurt, Ombudsman Taylor Holmes, Jacqueline Juarez, Supervising Governmental Auditor, Xiaoi Ni, General Auditor, and Joel Goldman, attorney for licensee. Meeting was held virtually via Teams Meeting. The following topics were addressed at this meeting:

Loss of control of property

60-day notice of eviction given to facility by landlord

60-day eviction notices for residents

Eviction Procedures

Auditing documents requested

Other documents requested

On 2-24-22, regional office received a complaint allegation of facility not paying bills. Regional office opened complaint on 2-25-22 and requested documentation including but not limited to grocery receipts, rent payments, utility bills, liability insurance, and lease agreement. On 2-28-22, regional office learned of a 60-day notice for licensee to vacate premises was issued by landlord.

A copy of the 60-day eviction notice to facility was received on 3-2-22. On 3-9-22, regional office learned that all residents have moved out and facility was vacant. Also discussed with licensee were the requirements to demonstrate control of property through a lease agreement as well as adequate liability insurance which meet regulatory requirements. {Cont. on 809C}

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PLACE CALLED HOME	FACILITY NUMBER: 392701008
	VISIT DATE: 03/10/2022

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Additionally, closure plan was discussed with licensee which includes a closure roster to be submitted to regional office as well as copies of notices of eviction due to closure issued to residents and their families. Regulation regarding the proper contents of the eviction letters was discussed. It was learned during this meeting that 60-day eviction notices due to closure were not furnished by licensee to residents or there responsible parties. Licensee and Licnesee’s Attorney expressed during this meeting that residents were not evicted and moved to licensee’s other facilities located in Modesto and Ripon after being offered the opportunity by licensee. LPM discussed reporting requirements regarding notification of licensee receiving a 60-day notice of eviction by landlord stating rent default. It was determined at this meeting that a written incident report was not submitted to regional office regarding this notification by landlord. Licensee stated that all residents have moved out of the facility with three residents previously giving a 30-day notice. Resident rights were discussed regarding resident’s option for additional resources for living arrangements.

Regional office audit department is currently investigating the latest allegation of facility not paying bills. During this meeting, auditor stated the following documents requested: LIC 401A, 403, 403A, 12-months of bank statements, 6 months of utility bills, quarterly taxes for payroll, proof of rent payments, and a copy of the lease. LPA Bilger requested a copy of liability insurance. A final clarified list of items will be submitted to licensee with due date of 4-10-22 for submittal to auditors.

Documents requested by regional office include: Copy of liability insurance, copy of 30-day notices submitted by residents, and closure roster.

As a result of today’s informal meeting, deficiencies are issued under Title 22, Division 6. An exit interview was conducted with Nataley Martinez and a copy of will be emailed to Nataley with request for return with signature. Appeal rights provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/10/2022 05:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PLACE CALLED HOME	FACILITY NUMBER: 392701008
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/17/2022 Section Cited	1 2 3 4 5 6 7	(d) The licensee shall notify the Department, the State Long-Term Care Ombudsman, all residents, and, if applicable, their representatives, in writing within two business days of any of the following specified events...
	8 9 10 11 12 13 14	(4) The licensee receives a written notice of default of payment of rent...This requirement is not met as evidenced by: Based on interview, licensee did not notify department of a received 60-day eviction notice due to rent default. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC809 (FAS) - (06/04)

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